Net benefit and cost-effectiveness of universal iron-containing multiple micronutrient powders for young children in 78 countries: a microsimulation study

The Effect of Iron Supplements on the Gut Microbiome of Females of Reproductive Age: A Randomized Controlled Trial

BACKGROUND

Iron deficiency is the most common nutritional deficiency worldwide, particularly for young children and females of reproductive age. Although oral iron supplements are routinely recommended and generally considered safe, iron supplementation has been shown to alter the fecal microbiota in low-income countries. Little is known about the effect of iron supplementation on the fecal microbiota in high-income settings.

OBJECTIVES

To assess the effect of oral iron supplementation compared with placebo on the gut microbiome in nonpregnant females of reproductive age in a high-income country.

METHODS

A 21-d prospective parallel design double-blind, randomized control trial conducted in South Australia, Australia. Females (18-45 y) were randomly assigned to either iron (65.7 mg ferrous fumarate) or placebo. Fecal samples were collected prior to commencing supplements and after 21 d of supplementation. The primary outcome was microbiota β-diversity (paired-sample weighted unique fraction metric dissimilarity) between treatment and placebo groups after 21 d of supplementation. Exploratory outcomes included changes in the relative abundance of bacterial taxa.

RESULTS

Of 82 females randomly assigned, 80 completed the trial. There was no significant difference between the groups for weighted unique fraction metric dissimilarity (mean difference: 0.003; 95% confidence interval: -0.007, 0.014; P = 0.52) or relative abundance of common bacterial taxa or Escherichia-Shigella (q > 0.05).

CONCLUSIONS

Iron supplementation did not affect the microbiome of nonpregnant females of reproductive age in Australia. This trial was registered at clinicaltrials.gov as NCT05033483.

Haemoglobin thresholds to define anaemia from age 6 months to 65 years: estimates from international data sources

BACKGROUND

Detection of anaemia is crucial for clinical medicine and public health. Current WHO anaemia definitions are based on statistical thresholds (fifth centiles) set more than 50 years ago. We sought to establish evidence for the statistical haemoglobin thresholds for anaemia that can be applied globally and inform WHO and clinical guidelines.

METHODS

In this analysis we identified international data sources from populations in the USA, England, Australia, China, the Netherlands, Canada, Ecuador, and Bangladesh with sufficient clinical and laboratory information collected between 1998 and 2020 to obtain a healthy reference sample. Individuals with clinical or biochemical evidence of a condition that could reduce haemoglobin concentrations were excluded. We estimated haemoglobin thresholds (ie, 5th centiles) for children aged 6-23 months, 24-59 months, 5-11 years, and 12-17 years, and adults aged 18-65 years (including during pregnancy) for individual datasets and pooled across data sources. We also collated findings from three large-scale genetic studies to summarise genetic variants affecting haemoglobin concentrations in different ancestral populations.

FINDINGS

We identified eight data sources comprising 18 individual datasets that were eligible for inclusion in the analysis. In pooled analyses, the haemoglobin fifth centile was 104·4 g/L (90% CI 103·5-105·3) in 924 children aged 6-23 months, 110·2 g/L (109·5-110·9) in 1874 children aged 24-59 months, and 114·4 g/L (113·6-115·2) in 1839 children aged 5-11 years. Values diverged by sex in adolescents and adults. In pooled analyses, the fifth centile was 122·2 g/L (90% CI 121·3-123·1) in 1741 female adolescents aged 12-17 years and 128·2 g/L (126·4-130·0) in 1103 male adolescents aged 12-17 years. In pooled analyses of adults aged 18-65 years, the fifth centile was 119·7 g/L (90% CI 119·1-120·3) in 3640 non-pregnant females and 134·9 g/L (134·2-135·6) in 2377 males. Fifth centiles in pregnancy were 110·3 g/L (90% CI 109·5-111·0) in the first trimester (n=772) and 105·9 g/L (104·0-107·7) in the second trimester (n=111), with insufficient data for analysis in the third trimester. There were insufficient data for adults older than 65 years. We did not identify ancestry-specific high prevalence of non-clinically relevant genetic variants that influence haemoglobin concentrations.

INTERPRETATION

Our results enable global harmonisation of clinical and public health haemoglobin thresholds for diagnosis of anaemia. Haemoglobin thresholds are similar between sexes until adolescence, after which males have higher thresholds than females. We did not find any evidence that thresholds should differ between people of differering ancestries.

FUNDING

World Health Organization and the Bill & Melinda Gates Foundation.

Biology of Anemia: A Public Health Perspective

Our goal is to present recent progress in understanding the biological mechanisms underlying anemia from a public health perspective. We describe important advances in understanding common causes of anemia and their interactions, including iron deficiency (ID), lack of other micronutrients, infection, inflammation, and genetic conditions. ID develops if the iron circulating in the blood cannot provide the amounts required for red blood cell production and tissue needs. ID anemia develops as iron-limited red blood cell production fails to maintain the hemoglobin concentration above the threshold used to define anemia. Globally, absolute ID (absent or reduced body iron stores that do not meet the need for iron of an individual but may respond to iron supplementation) contributes to only a limited proportion of anemia. Functional ID (adequate or increased iron stores that cannot meet the need for iron because of the effects of infection or inflammation and does not respond to iron supplementation) is frequently responsible for anemia in low- and middle-income countries. Absolute and functional ID may coexist. We highlight continued improvement in understanding the roles of infections and inflammation in causing a large proportion of anemia. Deficiencies of nutrients other than iron are less common but important in some settings. The importance of genetic conditions as causes of anemia depends upon the specific inherited red blood cell abnormalities and their prevalence in the settings examined. From a public health perspective, each setting has a distinctive composition of components underlying the common causes of anemia. We emphasize the coincidence between regions with a high prevalence of anemia attributed to ID (both absolute and functional), those with endemic infections, and those with widespread genetic conditions affecting red blood cells, especially in sub-Saharan Africa and regions in Asia and Oceania.

Approaches to Address the Anemia Challenge

Anemia is a multifactorial condition; approaches to address it must recognize that the causal factors represent an ecology consisting of internal (biology, genetics, and health) and external (social/behavioral/demographic and physical) environments. In this paper, we present an approach for selecting interventions, followed by a description of key issues related to the multiple available interventions for prevention and reduction of anemia. We address interventions for anemia using the following 2 main categories: 1) those that address nutrients alone, and, 2) those that address nonnutritional causes of anemia. The emphasis will be on interventions of public health relevance, but we also consider the clinical context. We also focus on interventions at different stages of the life course, with a particular focus on women of reproductive age and preschool-age children, and present evidence on various factors to consider when selecting an intervention-inflammation, genetic mutations, nutrient delivery, bioavailability, and safety. Each section on an intervention domain concludes with a brief discussion of key research areas.

Influence of intermittent iron and folic acid supplementation on cognitive abilities among adolescent girls in northwestern Tanzania

Iron and folic acid (IFA) supplementation to reduce anemia is key for improving substantial lost disability adjusted life years (DALYs) for adolescent girls. This study assessed the impact of weekly IFA supplementation (WIFAS) on cognitive ability among adolescent girls in the Simiyu Region in northernwestern Tanzania. This cross-sectional comparative evaluation study of 770 adolescent girls (396 -WIFAS supplemented; 374 -not supplemented) evaluated the association between WIFAS and cognitive ability through a face-to-face survey and cognitive ability assessment using standardized tests (Span-forward Test, Span-backward Test and Maze Test). Using a modified Poisson regression, we controlled for the geographic setting (urban vs rural), availability of potable water and feeding programs in schools, age and school level of adolescent girls, parental status, main parental economic activities, and the number of teachers. Participants were between the ages of 11 and 19 years, with more than half (57%) between 12-15 years of age. Those with WIFAS had higher cognitive ability (Span-forward scores, χ2 = 46.34% p <0.001; Span-forward, χ2 = 46.34% p <0.001; and Global Composite Cognitive Performance (GCCP), χ2 = 32.52% p<0.001). Among the IFA supplemented adolescent girls, secondary school level had a significantly higher score with respect to Span-backward (aPR = 1.43, 95% CI = 1.06-1.62); Span-forward ability (aPR = 1.26, 95% CI = 1.04-1.53) and Maze Test ability (aPR = 1.12, 95% CI = 1.01-1.25) as compared to their counterpart in primary school level. Individual adolescent girls with WIFAS and living with both parents performed much better on the Span-backward Test (aPR = 1.22, 95% CI = 1.07-1.68) as compared to those living with relatives and/or orphans. The presence of potable water program among the WIFAS schools resulted in a higher Span-backward ability (aPR = 1.34, 95% CI = 1.03-1.89); and GCCP (aPR = 1.27, 95% CI = 1.03-1.75). Adolescent girls from WIFAS schools with feeding program had higher Span-forward (aPR = 1.38, 95% CI = 1.03-1.63) ability as well as a higher Maze Test (aPR = 1.15, 95% CI = 1.07-1.26) score. The present study provides compelling evidence that WIFAS is positively associated with higher cognitive ability among adolescent girls. Nevertheless, IFA interventions are still rare in communities across Tanzania.

Protocol for a randomised, multicentre, four-arm, double-blinded, placebo-controlled trial to assess the benefits and safety of iron supplementation with malaria chemoprevention to children in Malawi: IRMA trial

INTRODUCTION

Approximately 40% of children aged 6-59 months worldwide are anaemic. Iron-containing multiple micronutrient powders (MNPs) and iron supplements (syrup/drops) are used to combat anaemia in children in different parts of the world. However, evidence for functional benefits of iron supplementation in children is scarce, and potential risks remain poorly defined, particularly concerning diarrhoea and malaria. This trial aims to determine if: (1) the efficacy of iron supplements or MNPs (containing iron) given with malaria chemoprevention is superior to malaria chemoprevention alone, or (2) if the efficacy of malaria chemoprevention alone is superior to placebo on child cognitive development.

METHODS AND ANALYSIS

IRMA is a four-arm, parallel-group, double-blinded, placebo-controlled, triple-dummy, randomised trial in Southern Malawi. The study recruits 2168 infants aged 6 months, with an intervention period of 6 months and a post-intervention period of a further 6 months. Children are randomised into four arms: (1) No intervention (placebo); (2) malaria chemoprevention only; (3) MNPs and malaria chemoprevention; and (4) iron syrup and malaria chemoprevention. The primary outcome, cognitive development (Cognitive Composite Score (CogCS)), is measured at the end of the 6 months intervention. Secondary outcomes include CogCS at a further 6 months post-intervention, motor, language and behavioural development, physical growth and prevalence of anaemia and iron deficiency. Safety outcomes include incidence of malaria and other infections, and prevalence of malaria parasitaemia during and post-intervention period.

ETHICS AND DISSEMINATION

The trial is approved by the National Health Sciences Research Committee (#19/01/2213) (Malawi) and the Human Research Ethics Committee (WEHI: 19/012) (Australia). Written informed consent in the local language is obtained from each participant before conducting any study-related procedure. Results will be shared with the local community and internationally with academic and policy stakeholders.

TRIAL REGISTRATION NUMBER

ACTRN12620000386932.

The cost-effectiveness of small-quantity lipid-based nutrient supplements for prevention of child death and malnutrition and promotion of healthy development: modelling results for Uganda

OBJECTIVE

Recent meta-analyses demonstrate that small-quantity lipid-based nutrient supplements (SQ-LNS) for young children significantly reduce child mortality, stunting, wasting, anaemia and adverse developmental outcomes. Cost considerations should inform policy decisions. We developed a modelling framework to estimate the cost and cost-effectiveness of SQ-LNS and applied the framework in the context of rural Uganda.

DESIGN

We adapted costs from a costing study of micronutrient powder (MNP) in Uganda, and based effectiveness estimates on recent meta-analyses and Uganda-specific estimates of baseline mortality and the prevalence of stunting, wasting, anaemia and developmental disability.

SETTING

Rural Uganda.

PARTICIPANTS

Not applicable.

RESULTS

Providing SQ-LNS daily to all children in rural Uganda (> 1 million) for 12 months (from 6 to 18 months of age) via the existing Village Health Team system would cost ∼$52 per child (2020 US dollars) or ∼$58·7 million annually. SQ-LNS could avert an average of > 242 000 disability-adjusted life years (DALYs) annually as a result of preventing 3689 deaths, > 160 000 cases of moderate or severe anaemia and ∼6000 cases of developmental disability. The estimated cost per DALY averted is $242.

CONCLUSIONS

In this context, SQ-LNS may be more cost-effective than other options such as MNP or the provision of complementary food, although the total cost for a programme including all age-eligible children would be high. Strategies to reduce costs, such as targeting to the most vulnerable populations and the elimination of taxes on SQ-LNS, may enhance financial feasibility.

Universal iron supplementation: the best strategy to tackle childhood anaemia in malaria-endemic countries?

Iron deficiency presents a major public health concern in many malaria-endemic regions, and both conditions affect young children most severely. Daily iron supplementation is the standard public health intervention recommended to alleviate rates of iron deficiency in children, but there is controversy over whether universal supplementation could increase the incidence and severity of malaria infection. Current evidence suggests that iron supplementation of deficient individuals is safe and effective in high-transmission settings when accompanied by malaria prevention strategies. However, low-resource settings often struggle to effectively control the spread of malaria, and it remains unclear whether supplementation of iron replete individuals could increase their risk of malaria and other infections. This review explores the evidence for and against universal iron supplementation programmes, and alternative strategies that could be used to alleviate iron deficiency in malaria-endemic areas, while minimising potential harm.

Statistical haemoglobin thresholds to define anaemia across the lifecycle

Detection of anaemia is critical for clinical medicine and public health. Current WHO values that define anaemia are statistical thresholds (5 ^th centile) set over 50 years ago, and are presently <110g/L in children 6-59 months, <115g/L in children 5-11 years, <110g/L in pregnant women, <120g/L in children 12-14 years of age, <120g/L in non-pregnant women, and <130g/L in men. Haemoglobin is sensitive to iron and other nutrient deficiencies, medical illness and inflammation, and is impacted by genetic conditions; thus, careful exclusion of these conditions is crucial to obtain a healthy reference population. We identified data sources from which sufficient clinical and laboratory information was available to determine an apparently healthy reference sample. Individuals were excluded if they had any clinical or biochemical evidence of a condition that may diminish haemoglobin concentration. Discrete 5 ^th centiles were estimated along with two-sided 90% confidence intervals and estimates combined using a fixed-effect approach. Estimates for the 5 ^th centile of the healthy reference population in children were similar between sexes. Thresholds in children 6-23 months were 104.4g/L [90% CI 103.5, 105.3]; in children 24-59 months were 110.2g/L [109.5, 110.9]; and in children 5-11 years were 114.1g/L [113.2, 115.0]. Thresholds diverged by sex in adolescents and adults. In females and males 12-17 years, thresholds were 122.2g/L [121.3, 123.1] and 128.2 [126.4, 130.0], respectively. In adults 18-65 years, thresholds were 119.7g/L [119.1, 120.3] in non-pregnant females and 134.9g/L [134.2, 135.6] in males. Limited analyses indicated 5 ^th centiles in first-trimester pregnancy of 110.3g/L [109.5, 111.0] and 105.9g/L [104.0, 107.7] in the second trimester. All thresholds were robust to variations in definitions and analysis models. Using multiple datasets comprising Asian, African, and European ancestries, we did not identify novel high prevalence genetic variants that influence haemoglobin concentration, other than variants in genes known to cause important clinical disease, suggesting non-clinical genetic factors do not influence the 5 ^th centile between ancestries. Our results directly inform WHO guideline development and provide a platform for global harmonisation of laboratory, clinical and public health haemoglobin thresholds.

A Systematic Review of Health Economic Evaluations and Budget Impact Analyses to Inform Healthcare Decision-Making in Central America

BACKGROUND

Little is known about the quality, quantity and disease areas analysed by health economic research that inform healthcare decision-making in Central America. This study aimed to review the existing health economic evaluations (HEEs) and budget impact analyses (BIAs) evidence in Central America based on scope and reporting quality.

METHODS

HEEs and BIAs published from 2000 to April 2021 were searched in five electronic databases: PubMed, Embase, LILACS (Latin American and Caribbean Health Science Literature), EconLIT and OVID Global Health. Two reviewers assessed titles, abstracts and full texts of studies for eligibility. The quality appraisal for the reporting was based on La Torre and colleagues' version of the Drummond checklist and the ISPOR good practices for BIA. For each country, we correlated the number of studies by disease area with their respective burden of disease to identify under-researched health areas.

RESULTS

102 publications were eligible for this review. Ninety-four publications reported a HEE, six publications reported a BIA, and two studies reported both a HEE and a BIA. Costa Rica had the highest number of publications (n = 28, 27.5%), followed by Guatemala (n = 25, 24.5%). Cancer and respiratory infections were the most common types of disease studied. Diabetes mellitus, chronic kidney diseases, and mental disorders were under-researched relative to their disease burden in most of the countries. The overall mean quality reporting score for HEE and BIA studies were 71/119 points (60%) and 7/10 points (70%), respectively; however, these assessments were made on different scales.

CONCLUSION

In Central America, health economic research is sparse and is considered as suboptimal quality for reporting. The findings reported information useful to other low- and middle-income countries with similar advances in the application of economics to promote health policy decision-making.

Deep Brain Stimulation for Advanced Parkinson Disease in Developing Countries: A Cost-Effectiveness Study From China

BACKGROUND

The cost-effectiveness of deep brain stimulation (DBS) is more favorable than best medical treatment (BMT) for advanced Parkinson disease (PD) in developed countries. However, it remains unclear in developing countries, where the cost of DBS may not be reimbursed by health care system.

OBJECTIVE

To model and evaluate the long-term cost-effectiveness of DBS for advanced PD in China from a patient payer perspective.

METHODS

We developed a Markov model representing the clinical progress of PD to predict the disease progression and related medical costs in a 15-year time horizon. The incremental cost-effectiveness ratio (ICER) and net benefit were used to evaluate the cost-effectiveness of DBS vs BMT.

RESULTS

DBS treatment led to discounted total costs of ¥370 768 ($56 515.20) (95% CI, ¥369 621.53-371 914.88), compared with ¥48 808 ($7439.68) (95% CI, ¥48 502.63-49 114.21) for BMT, with an additional 1.51 quality-adjusted life years gained, resulting in an ICER of ¥213 544 ($32 549.96)/quality-adjusted life years (95% CI, ¥208 177.35-218 910.10). Sensitivity analysis showed that DBS-related cost has the most substantial impact on ICER. Nation-wide net benefit of BMT and DBS were ¥33 819 ($5154.94) (95% CI, ¥30 211.24-37 426) and ¥30 361 ($4627.85) (95% CI, ¥25 587.03-39 433.66), respectively. Patient demographic analysis showed that more favorable DBS cost-effectiveness was associated with younger age and less severe disease stage.

CONCLUSION

DBS is cost-effective for patients with advanced PD over a 15-year time horizon in China. However, compared with developed countries, DBS remains a substantial economic burden for patients when no reimbursement is provided. Our findings may help inform cost-effectiveness-based decision making for clinical care of PD in developing countries.

Effects of iron supplementation on neural indices of habituation in Bangladeshi children

BACKGROUND

Iron deficiency and anemia have been associated with poor cognition in children, yet the effects of iron supplementation on neurocognition remain unclear.

OBJECTIVE

We aimed to examine the effects of supplementation with iron on neural indices of habituation using auditory event-related brain potentials (ERPs).

METHODS

This substudy was nested within a 3-arm, double-blind, double-dummy, individual randomized trial in Bangladesh, in which 3300 8-mo-old children were randomly selected to receive 3 mo of daily iron syrup (12.5 mg iron), multiple micronutrient powders (MNPs) (including 12.5 mg iron), or placebo. Children were assessed after 3 mo of intervention (mo 3) and 9 mo thereafter (mo 12). The neurocognitive substudy comprised a randomly selected subset of children from the main trial. Brain activity elicited during an auditory roving oddball task was recorded using electroencephalography to provide an index of habituation. The differential response to a novel (deviant) compared with a repeated (standard) sound was examined. The primary outcome was the amplitude of the mismatch response (deviant minusstandard tone waveforms) at mo 3. Secondary outcomes included the deviant and standard tone-evoked amplitudes, N2 amplitude differences, and differences in mean amplitudes evoked by deviant tones presented in the second compared with first half of the oddball sequence at mo 3 and 12.

RESULTS

Data were analyzed from 329 children at month 3 and 363 at mo 12. Analyses indicated no treatment effects of iron interventions compared with placebo on the amplitude of the mismatch response (iron syrup compared with placebo: mean difference (MD) = 0.07μV [95% CI: -1.22, 1.37]; MNPs compared with placebo: MD = 0.58μV [95% CI: -0.74, 1.90]) nor any secondary ERP outcomes at mo 3 or 12, despite improvements in hemoglobin and ferritin concentrations from iron syrup and MNPs in this nested substudy.

CONCLUSION

In Bangladeshi children with >40% anemia prevalence, iron or MNP interventions alone are insufficient to improve neural indices of habituation. This trial was registered at the Australian New Zealand Clinical Trials Registry as ACTRN12617000660381.

Hepcidin-guided screen-and-treat interventions for young children with iron-deficiency anaemia in The Gambia: an individually randomised, three-arm, double-blind, controlled, proof-of-concept, non-inferiority trial

BACKGROUND

Iron deficiency is the most prevalent nutritional disorder worldwide. Iron supplementation has modest efficacy, causes gastrointestinal side-effects that limit compliance, and has been associated with serious adverse outcomes in children across low-income settings. We aimed to compare two hepcidin-guided screen-and-treat regimens designed to reduce overall iron dosage by targeting its administration to periods when children were safe and ready to receive iron supplementation, with WHO's recommendation of universal iron supplementation.

METHODS

We conducted an individually randomised, three-arm, double-blind, controlled, proof-of-concept, non-inferiority trial in 12 rural communities across The Gambia. Eligible participants were children aged 6-23 months with anaemia. Participants were randomly assigned (1:1:1) to either the WHO recommended regimen of one sachet of multiple micronutrient powder (MMP) daily containing 12·0 mg iron as encapsulated ferrous fumarate (control group); to MMP with 12·0 mg per day iron for the next 7 days if plasma hepcidin concentration was less than 5·5 μg/L, or to MMP without iron for the next 7 days if plasma hepcidin concentration was at least 5·5 μg/L (12 mg screen-and-treat group); or to MMP with 6·0 mg per day iron for the next 7 days if plasma hepcidin concentration was less than 5·5 μg/L, or to MMP without iron for the next 7 days if plasma hepcidin concentration was at least 5·5 μg/L (6 mg screen-and-treat group). Randomisation was done by use of a permuted block design (block size of 9), with stratification by haemoglobin and age, using computer-generated numbers. Participants and the research team (except for the data manager) were masked to group allocation. The primary outcome was haemoglobin concentration, with a non-inferiority margin of -5 g/L. A per-protocol analysis, including only children who had consumed at least 90% of the supplements (ie, supplement intake on ≥75 days during the study), was done to assess non-inferiority of the primary outcome at day 84 using a one-sided t test adjusted for multiple comparisons. Safety was assessed by use of ex-vivo growth tests of Plasmodium falciparum in erythrocytes and three species of sentinel bacteria in plasma samples from participants. This trial is registered with the ISRCTN registry, ISRCTN07210906.

FINDINGS

Between April 23, 2014, and Aug 7, 2015, we prescreened 783 children, of whom 407 were enrolled into the study: 135 were randomly assigned to the control group, 136 to the 12 mg screen-and-treat group, and 136 to the 6 mg screen-and-treat group. 345 (85%) children were included in the per-protocol population: 115 in the control group, 116 in the 12 mg screen-and-treat group, and 114 in the 6 mg screen-and-treat group. Directly observed adherence was high across all groups (control group 94·8%, 12 mg screen-and-treat group 95·3%, and 6 mg screen-and-treat group 95·0%). 82 days of iron supplementation increased mean haemoglobin concentration by 7·7 g/L (95% CI 3·2 to 12·2) in the control group. Both screen-and-treat regimens were significantly less efficacious at improving haemoglobin (-5·6 g/L [98·3% CI -9·9 to -1·3] in the 12 mg screen-and-treat group and -7·8 g/L [98·3% CI -12·2 to -3·5] in the 6 mg screen-and-treat group) and neither regimen met the preset non-inferiority margin of -5 g/L. The 12 mg screen-and-treat regimen reduced iron dosage to 6·1 mg per day and the 6 mg screen-and-treat regimen reduced dosage to 3·0 mg per day. 580 adverse events were observed in 316 participants, of which eight were serious adverse events requiring hospitalisation mainly due to diarrhoeal disease (one [1%] participant in the control group, three [2%] in the 12 mg screen-and-treat group, and four [3%] in the 6 mg screen-and-treat group). The most common causes of non-serious adverse events (n=572) were diarrhoea (145 events [25%]), upper respiratory tract infections (194 [34%]), lower respiratory tract infections (62 [11%]), and skin infections (122 [21%]). No adverse events were deemed to be related to the study interventions.

INTERPRETATION

The hepcidin-guided screen-and-treat strategy to target iron administration succeeded in reducing overall iron dosage, but was considerably less efficacious at increasing haemoglobin and combating iron deficiency and anaemia than was WHO's standard of care, and showed no differences in morbidity or safety outcomes.

FUNDING

Bill & Melinda Gates Foundation and UK Medical Research Council.

An implementation research programme to support an intravenous iron intervention for pregnant women with moderate and severe anaemia in Malawi: study protocol

Background

Antenatal iron supplementation is critical to maternal and child health; however, access and adherence to oral iron are inconsistent in many low- and middle-income countries (LMICs). Modern intravenous (IV) iron products have become available in high-income clinical settings and provide an opportunity to deliver high doses of iron in a single-short infusion during pregnancy. However, there is limited knowledge of the drivers and barriers for such an intervention to be effectively delivered and upscaled in LMICs. In this study protocol, we describe the implementation research programme to support an IV iron intervention in Malawi for pregnant women with moderate and severe anaemia.

Methods

The implementation research programme has three phases, each guided by implementation science conceptual frameworks. In Phase 1, we will conduct formative research (context assessment of the health system with key informant interviews) to determine how IV iron can be effectively introduced into routine antenatal care. We will use the findings to co-develop potential strategies with end-users and healthcare providers to improve intervention implementation. In Phase 2, we will disseminate the implementation strategies to support the uptake and delivery of the intervention in the study settings. In Phase 3, the intervention will be implemented, and we will conduct formative evaluation (interviews with end-users, healthcare providers, and analysis of health services data) to investigate the feasibility and acceptability of the intervention and strategies. We will also identify processes and contextual factors that facilitate or impede the delivery and uptake of IV iron.

Discussion

In LMICs, modern IV iron products present a novel opportunity to rapidly cure moderate and severe anaemia in pregnancy, thereby improving maternal and child health outcomes. This implementation research programme will provide guidance and recommendations on how best an IV iron intervention for pregnant women with anaemia can be implemented in an LMIC setting like Malawi. We will develop locally relevant and culturally appropriate implementation strategies by engaging with key stakeholders (pregnant women, healthcare providers, and policymakers) and identifying factors likely to facilitate successful implementation. The findings of this research can guide the implementation of an IV iron intervention in Malawi and other LMICs.

Cost-effectiveness of universal iron supplementation and iron-containing micronutrient powders for anemia among young children in rural Bangladesh: analysis of a randomized, placebo-controlled trial

BACKGROUND

Universal provision of iron supplements or iron-containing multiple micronutrient powders (MNPs) is widely used to prevent anemia in young children in low- and middle-income countries. The BRISC (Benefits and Risks of Iron Interventions in Children) trial compared iron supplements and MNPs with placebo in children <2 y old in rural Bangladesh.

OBJECTIVES

We aimed to assess the cost-effectiveness of iron supplements or iron-containing MNPs among young children in rural Bangladesh.

METHODS

We did a cost-effectiveness analysis of MNPs and iron supplements using the BRISC trial outcomes and resource use data, and programmatic data from the literature. Health care costs were assessed from a health system perspective. We calculated incremental cost-effectiveness ratios (ICERs) in terms of US$ per disability-adjusted life-year (DALY) averted. To explore uncertainty, we constructed cost-effectiveness acceptability curves using bootstrapped data over a range of cost-effectiveness thresholds. One- and 2-way sensitivity analyses tested the impact of varying key parameter values on our results.

RESULTS

Provision of MNPs was estimated to avert 0.0031 (95% CI: 0.0022, 0.0041) DALYs/child, whereas iron supplements averted 0.0039 (95% CI: 0.0030, 0.0048) DALYs/child, over 1 y compared with no intervention. Incremental mean costs were $0.75 (95% CI: 0.73, 0.77) for MNPs compared with no intervention and $0.64 ($0.62, $0.67) for iron supplements compared with no intervention. Iron supplementation dominated MNPs because it was cheaper and averted more DALYs. Iron supplementation had an ICER of $1645 ($1333, $2153) per DALY averted compared with no intervention, and had a 0% probability of being the optimal strategy at cost-effectiveness thresholds of $200 (reflecting health opportunity costs in Bangladesh) and $985 [half of gross domestic product (GDP) per capita] per DALY averted. Scenario and sensitivity analyses supported the base case findings.

CONCLUSIONS

These findings do not support universal iron supplementation or micronutrient powders as a cost-effective intervention for young children in rural Bangladesh.This trial was registered at anzctr.org.au as ACTRN1261700066038 and trialsearch.who.int as U1111-1196-1125.

Prevalence of, and factors associated with anaemia in children aged 1-3 years in Aceh, Indonesia: A cross-sectional study

Background: Child anaemia continues to represent a major public health challenge in lower-and-middle income countries. It has serious long-term consequences for child growth and development. In Indonesia, there was a 10% increase in the national prevalence of child anaemia between 2013 and 2018. Aim: This study aims to assess the prevalence of, and factors associated with anaemia among children aged one to three years in eight districts in Aceh Province, Indonesia. Methods: A cross-sectional study was conducted on a sample of 1148 mother-child dyads aged one to three years between November and December 2018. The sampling process involved a three-stage cluster sampling design using the probability proportionate to size methodology. Anaemia status was determined using haemoglobin level (Hb < 11.0 g/dL). Data were analysed using multivariable logistic regression to estimate adjusted odds ratios (aOR) and their 95% confidence intervals (95% CI) for associated factors. Results: The overall prevalence of anaemia was 76.1% (869/1142). 44.7% (510/1142) and 28.6% (327/1142) had moderate and mild anaemia, respectively. Child aged 12-24 months (aOR: 2.00, 95% CI: 1.26-3.17), not receiving routine immunisation (aOR: 2.62, 95% CI: 1.34-5.10), and maternal anaemia (aOR: 2.15, 95% CI: 1.59-2.90) were significantly associated with anaemia. Conclusion: The prevalence of anaemia among the children in this study was high, and was associated with child age, immunisation status, and maternal anaemia. These findings provide further insight into anaemia as a public health issue at a sub-national level in Indonesia and for development of targeted programmes to address associated risk factors of child anaemia.

Iron Status, Anemia, and Iron Interventions and Their Associations with Cognitive and Academic Performance in Adolescents: A Systematic Review

In adolescents, iron-deficiency anemia is the leading cause of disability-adjusted life years lost. The World Health Organization recommends delivering iron supplementation through school-based platforms, requiring partnerships with the education sector. This anemia-reduction intervention is valued for the perceived benefits of improved learning and school performance. This article aims to systematically review the available evidence on the relationship between iron status and anemia and impacts of iron interventions on cognitive and academic performance in adolescents. Fifty studies were included: n = 26 cross-sectional and n = 24 iron-containing interventions. Our review suggests that iron status and anemia may be associated with academic performance in some contexts and that iron supplementation during adolescence may improve school performance, attention, and concentration. However, nearly all supplementation trials were judged to have moderate or high risk of bias. We did not find evidence suggesting that iron status and anemia influenced or were associated with attention, intelligence, nor memory in adolescents. Further, iron supplementation did not improve memory and recall or intelligence. Overall, more high-quality research is needed to guide programmers and policy makers to understand the relationships between anemia and educational performance and the potential impacts of iron interventions, which effectively reduce anemia, on adolescents’ learning and school performance.

High impact health service interventions for attainment of UHC in Africa: A systematic review

African countries have prioritized the attainment of targets relating to Universal Health Coverage (UHC), Health Security (HSE) and Coverage of Health Determinants (CHD)to attain their health goals. Given resource constraints, it is important to prioritize implementation of health service interventions with the highest impact. This is important to be identified across age cohorts and public health functions of health promotion, disease prevention, diagnostics, curative, rehabilitative and palliative interventions. We therefore explored the published evidence on the effectiveness of existing health service interventions addressing the diseases and conditions of concern in the Africa Region, for each age cohort and the public health functions. Six public health and economic evaluation databases, reports and grey literature were searched. A total of 151 studies and 357 interventions were identified across different health program areas, public health functions and age cohorts. Of the studies, most were carried out in the African region (43.5%), on communicable diseases (50.6%), and non-communicable diseases (36.4%). Majority of interventions are domiciled in the health promotion, disease prevention and curative functions, covering all age cohorts though the elderly cohort was least represented. Neonatal and communicable conditions dominated disease burden in the early years of life and non-communicable conditions in the later years. A menu of health interventions that are most effective at averting disease and conditions of concern across life course in the African region is therefore consolidated. These represent a comprehensive evidence-based set of interventions for prioritization by decision makers to attain desired health goals. At a country level, we also identify principles for identifying priority interventions, being the targeting of higher implementation coverage of existing interventions, combining interventions across all the public health functions-not focusing on a few functions, provision of subsidies or free interventions and prioritizing early identification of high-risk populations and communities represent these principles.

Characteristics that modify the effect of small-quantity lipid-based nutrient supplementation on child growth: an individual participant data meta-analysis of randomized controlled trials

BACKGROUND

Meta-analyses show that small-quantity lipid-based nutrient supplements (SQ-LNSs) reduce child stunting and wasting. Identification of subgroups who benefit most from SQ-LNSs may facilitate program design.

OBJECTIVES

We aimed to identify study-level and individual-level modifiers of the effect of SQ-LNSs on child growth outcomes.

METHODS

We conducted a 2-stage meta-analysis of individual participant data from 14 randomized controlled trials of SQ-LNSs provided to children 6-24 mo of age (n = 37,066). We generated study-specific and subgroup estimates of SQ-LNS compared with control and pooled the estimates using fixed-effects models. We used random-effects meta-regression to examine study-level effect modifiers. In sensitivity analyses, we examined whether results differed depending on study arm inclusion criteria and types of comparisons.

RESULTS

SQ-LNS provision decreased stunting (length-for-age z score < -2) by 12% (relative reduction), wasting [weight-for-length (WLZ) z score < -2] by 14%, low midupper arm circumference (MUAC) (<125 mm or MUAC-for-age z score < -2) by 18%, acute malnutrition (WLZ < -2 or MUAC < 125 mm) by 14%, underweight (weight-for-age z score < -2) by 13%, and small head size (head circumference-for-age z score < -2) by 9%. Effects of SQ-LNSs generally did not differ by study-level characteristics including region, stunting burden, malaria prevalence, sanitation, water quality, duration of supplementation, frequency of contact, or average compliance with SQ-LNS. Effects of SQ-LNSs on stunting, wasting, low MUAC, and small head size were greater among girls than among boys; effects on stunting, underweight, and low MUAC were greater among later-born (than among firstborn) children; and effects on wasting and acute malnutrition were greater among children in households with improved (as opposed to unimproved) sanitation.

CONCLUSIONS

The positive impact of SQ-LNSs on growth is apparent across a variety of study-level contexts. Policy-makers and program planners should consider including SQ-LNSs in packages of interventions to prevent both stunting and wasting.This trial was registered at www.crd.york.ac.uk/PROSPERO as CRD42019146592.

Perspective: Putting the youngest among us into the nutrition "call for action" for food fortification strategies

Adequate iron intake is essential for optimal child development, but iron deficiency and anemia among infants and young children are widespread in low- and middle-income countries. Large-scale food fortification strategies hold great promise for reducing micronutrient deficiencies; however, for children <2 y of age, the impact of such strategies is limited because their intake of staple foods is relatively low and fortification levels are targeted at the adult population. Iron supplementation, iron fortification of foods targeted to infants, and point-of-use fortification with iron-containing products such as multiple micronutrient powders (MNPs) and small-quantity lipid-based nutrient supplements are evidence-based approaches recommended to reduce anemia among infants and young children when used in the right context. Since 2003, the WHO, with support from UNICEF, has recommended the use of MNPs to control iron deficiency. However, the percentage of children with anemia has changed very little over the past 10 y. Five years ago the UN declared a decade of action on nutrition, including World Health Assembly (WHA) targets for maternal, infant, and young child nutrition, yet the WHA set no anemia targets for children. In July 2020 the leaders of 4 UN agencies issued a call for action to protect children's right to nutrition in the face of the COVID-19 pandemic and beyond. Given persistently high rates of anemia among young children, the negative developmental impact, the challenge of meeting iron needs from typical complementary food diets, and the availability of successful evidence-based fortification strategies for this age group, we encourage planners, speakers, and donors at this year's UN Food Systems Summit and the Tokyo Nutrition for Growth Summit to 1) call for the WHA to set anemia targets for infants and young children and 2) promote investment in evidence-based interventions to improve the iron status of young children.

Iron deficiency anaemia in sub-Saharan Africa: a review of current evidence and primary care recommendations for high-risk groups

The epidemiology of iron deficiency anaemia in sub-Saharan Africa differs from that in other parts of the world. The low-quality diets prevalent in this region are a poor source of iron, the population is frequently exposed to infection, and demographic characteristics result in a greater prevalence of people at high risk of iron deficiency anaemia than in other parts of the world. We herein review the causes, disease burden, and consequences of iron deficiency anaemia in the general population in this region, and current policies and interventions for its control. The current debate is dominated by concerns about the safety of iron interventions, namely regarding its effects on malaria and other infectious diseases. However, universal antenatal iron supplementation and delayed cord clamping are safe interventions and stand out for their potential to improve maternal and infant health. Effective infection control is a precondition to safe and efficacious iron interventions in children. Greater emphasis should be given to approaches aiming to reduce iron loss due to helminth infections and menstruation, alongside interventions to increase iron intake. TRANSLATION: For the French translation of the abstract see Supplementary Materials section.

Economic Evaluations of Child Nutrition Interventions in Low- and Middle-Income Countries: Systematic Review and Quality Appraisal

Economic evaluation is crucial for cost-effective resource allocation to improve child nutrition in low and middle-income countries (LMICs). However, the quality of published economic evaluations in these settings is not well understood. This systematic review aimed to assess the quality of existing economic evaluations of child nutrition interventions in LMICs and synthesize the study characteristics and economic evidence. We searched 9 electronic databases, including MEDLINE, with the following concepts: economic evaluation, children, nutrition, and LMICs. All types of interventions addressing malnutrition, including stunting, wasting, micronutrient deficiency, and overweight, were identified. We included economic evaluations that examined both costs and effects published in English peer-reviewed journals and used the Drummond checklist for quality appraisal. We present findings through a narrative synthesis. Sixty-nine studies with diverse settings, perspectives, time horizons, and outcome measures were included. Most studies used data from sub-Saharan Africa and South Asia and addressed undernutrition. The mortality rate, intervention effect, intervention coverage, cost, and discount rate were reported as predictors among studies that performed sensitivity analyses. Despite the heterogeneity of included studies and the possibility of publication bias, 81% of included studies concluded that nutrition interventions were cost-effective or cost-beneficial, mostly based on a country's cost-effectiveness thresholds. Regarding quality assessment, the studies published after 2016 met more criteria than studies published before 2016. Most studies had well-stated research questions, forms of economic evaluation, interventions, and conclusions. However, reporting the perspective of the analyses, justification of discount rates, and describing the role of funders and ethics approval were identified as areas needing improvement. The gaps in the quality of reporting could be improved by consolidated guidance on the publication of economic evaluations and the use of appropriate quality appraisal checklists. Strengthening the evidence base for child malnutrition across different regions is necessary to inform cost-effective investment in LMICs. Trial registration: PROSPERO CRD42020194445.

Benefits and Risks of Iron Interventions in Infants in Rural Bangladesh

BACKGROUND

Universal provision of iron supplements (drops or syrup) or multiple micronutrient powders to young children in low-to-middle-income countries where anemia is prevalent is recommended by the World Health Organization and widely implemented. The functional benefits and safety of these interventions are unclear.

METHODS

We conducted a three-group, double-blind, double-dummy, individually randomized, placebo-controlled trial to assess the immediate and medium-term benefits and risks of 3 months of daily supplementation with iron syrup or iron-containing multiple micronutrient powders, as compared with placebo, in 8-month-old children in rural Bangladesh. The primary outcome was cognitive development, as assessed by the cognitive composite score on the Bayley Scales of Infant and Toddler Development, third edition, immediately after completion of the assigned 3-month regimen; scores range from 55 to 145, with higher scores indicating better cognitive performance. Secondary outcomes included the cognitive composite score at 9 months after completion of the assigned regimen; behavioral, language, and motor development, as well as growth and hematologic markers, immediately after completion and at 9 months after completion; and safety.

RESULTS

We randomly assigned 3300 infants to receive iron syrup (1101 infants), multiple micronutrient powders (1099), or placebo (1100) daily. After completion of the assigned 3-month regimen, no apparent effect on the cognitive composite score was observed with iron syrup as compared with placebo (mean between-group difference in change in score from baseline, -0.30 points; 95% confidence interval [CI], -1.08 to 0.48) or with multiple micronutrient powders as compared with placebo (mean between-group difference in change in score from baseline, 0.23 points; 95% CI, -0.55 to 1.00). No apparent effect on any other developmental or growth outcome was observed immediately after completion of the assigned regimen or at 9 months after completion. At 9 months after completion of the assigned regimen, the prevalences of anemia, iron deficiency, and iron deficiency anemia increased in all three trial groups but remained lower among the children who received iron syrup or multiple micronutrient powders than among those who received placebo. The risk of serious adverse events and incidence of symptoms of infection were similar in the three trial groups.

CONCLUSIONS

In this trial involving infants in Bangladesh, 3 months of daily supplementation with iron syrup or multiple micronutrient powders did not appear to have an effect on child development or other functional outcomes as compared with placebo. (Funded by the National Health and Medical Research Council of Australia; BRISC Australian New Zealand Clinical Trials Registry number, ACTRN12617000660381.).

Vaccine efficacy and iron deficiency: an intertwined pair?

Vaccines are the most effective measure to prevent deaths and illness from infectious diseases. Nevertheless, the efficacy of several paediatric vaccines is lower in low-income and middle-income countries (LMICs), where mortality from vaccine-preventable infections remains high. Vaccine efficacy can also be decreased in adults in the context of some common comorbidities. Identifying and correcting the specific causes of impaired vaccine efficacy is of substantial value to global health. Iron deficiency is the most common micronutrient deficiency worldwide, affecting more than 2 billion people, and its prevalence in LMICs could increase as food security is threatened by the COVID-19 pandemic. In this Viewpoint, we highlight evidence showing that iron deficiency limits adaptive immunity and responses to vaccines, representing an under-appreciated additional disadvantage to iron deficient populations. We propose a framework for urgent detailed studies of iron-vaccine interactions to investigate and clarify the issue. This framework includes retrospective analysis of newly available datasets derived from trials of COVID-19 and other vaccines, and prospective testing of whether nutritional iron interventions, commonly used worldwide to combat anaemia, improve vaccine performance.